Just do the ECV, Just do it - This, I call it a Miracle:" Understanding External Cephalic Version Practices at the Largest Teaching Hospital in Ghana.

Background: External cephalic version (ECV) is a proven, low-risk, low-resource, and cost-effective procedure, when performed by a skilled healthcare professional, to reduce cesarean delivery (CD) rates for malpresented fetuses. Information regarding ECV practices in low- and middle-income countries is limited. We sought to understand and evaluate malpresentation counseling, decision-making, and ECV practices from the perspective of clinicians and patients at the largest referral teaching hospital in Ghana. Methods: We conducted a prospective, multi-modal cohort study of obstetrics patients who were eligible for ECV at Korle Bu Teaching Hospital in Accra, Ghana between July 1 and December 31, 2024. We enrolled pregnant patients who were ≥ 36 weeks gestation diagnosed with malpresentation. After enrollment, the research team directly observed the patients' antenatal care visits to collect data on the counseling related to their malpresentation diagnosis, ECV if applicable, and obtained delivery information postpartum via their medical record. Postpartum, patients and their clinicians were recruited to complete semi-structured interviews to understand their perspectives and decision-making regarding ECV. We performed descriptive and inferential statistics including cross-tabulation with Chi-square analysis or Fisher's exact test for categorical variables and independent samples t-test or analysis of variance for continuous variables. Statistical significance was defined at p < 0.05. Interviews were audio-recorded, translated, transcribed, coded, and thematically analyzed. Results: Among 46 enrolled patients at 36 weeks' gestation who were eligible for ECV, only 21 (45.7%) were offered ECV, and 17 (37.0%) underwent ECV. History of one previous CD and training and resource limitations were barriers to clinicians offering ECV. Patients refrained from pursuing ECV if they lacked understanding of the procedure and its complications. Overall, patients and clinicians positively perceived ECV and valued its ability to decrease CD rates. Conclusions: This study demonstrates important opportunities to improve counseling, utilize evidence-based indications to offer ECV to patients with pregnancies complicated by malpresentation, and ensure clinicians-and potentially midwives-are trained to perform ECV. Addressing these opportunities successfully could improve the number of healthcare professionals who practice safe and effective ECV in sub-Saharan Africa and potentially decrease avoidable rates of CD and their associated morbidity and mortality.